# EMTALA violation: the ED records that prove or defeat it

> EMTALA claims under 42 USC 1395dd: the 3 duties, disparate screening, the 2-year limit, and the ED records and timestamps that prove or defeat them.

Canonical page: https://medrecords.ai/guides/emtala-violation-medical-records/

---
New — **Missing Records Detection:** flags every visit, provider, and date missing from the file. [See how →](https://medrecords.ai/product/missing-records-identification/)
Field guide, September 2026. 13 chapters.

## EMTALA violations: the emergency department records that prove or defeat the claim

For plaintiff med-mal and PI attorneys, legal nurse consultants and ED nurse experts working an EMTALA claim. You walk away with the rules, the record set to request, a timestamp method, and 2 templates.

By [Ahmed Jemaa](https://medrecords.ai/authors/ahmed-jemaa/), Co-Founder and CEO, Medrecords AI. Published 25 September 2026.

An EMTALA violation is a Medicare-participating hospital's failure, when someone comes to its emergency department, to give an appropriate medical screening examination, to stabilize an emergency medical condition it finds, or to transfer an unstable patient only as the statute allows. Under 42 USC 1395dd(d)(2), a harmed patient can sue the hospital, not the physicians, within 2 years. Timestamped ED records prove or defeat the claim.

An EMTALA case is won or lost on a clock. The question is rarely whether the emergency department did good medicine; it is whether the hospital screened this patient the way it screens everyone with the same complaint, whether it stabilized what it found, and whether the transfer paperwork existed before the ambulance doors closed.

This guide is built from the statute at 42 USC 1395dd, the Medicare regulations at 42 CFR 489.20 and 489.24, the HHS civil monetary penalty table at 45 CFR 102.3, the CMS State Operations Manual Appendix V (the EMTALA interpretive guidelines surveyors use, Rev. 191), CMS survey memo S&C 13-21 on public release of Form CMS-2567 and 2 court opinions, *Roberts v. Galen of Virginia* (1999) and *Marshall v. East Carroll Parish Hospital Service District* (1998). Every case example is a labeled hypothetical. Nothing here is legal or medical advice. Damages rules, caps, pre-suit requirements and evidence rules vary by state and circuit; check your jurisdiction.

8 numbers

### EMTALA in 8 numbers

3 duties
screen, stabilize, and restrict transfer of the unstable patient
42 USC 1395dd(a), (b), (c)
2 years
from the date of the violation to bring the civil action
42 USC 1395dd(d)(2)(C)
5 years
both hospitals must keep records of a transferred patient
42 CFR 489.20(r)(1)
$136,886
maximum adjusted penalty per violation, hospital of 100+ beds or a responsible physician (2025)
45 CFR 102.3
$68,445
maximum adjusted penalty per violation, hospital under 100 beds (2025)
45 CFR 102.3
72 hours
for a receiving hospital to report a suspected improper transfer
CMS SOM Appendix V
20 records
minimum sample a surveyor reviews in depth in an EMTALA investigation
CMS SOM Appendix V, Task 2
60 days
QIO physician review period before CMS imposes a penalty, absent jeopardy
42 USC 1395dd(d)(3)
Chapter 1 Everyone

### What EMTALA requires: 3 duties and 1 prohibition

Congress passed the Emergency Medical Treatment and Labor Act in April 1986 as part of COBRA, aimed at "patient dumping": hospitals turning away or shipping out emergency patients who could not pay. It is section 1867 of the Social Security Act, codified at [42 USC 1395dd](https://www.law.cornell.edu/uscode/text/42/1395dd). It binds every hospital that has a Medicare provider agreement and an emergency department, and the definition of "hospital" includes critical access hospitals and rural emergency hospitals.

The statute is short. Its first duty is 1 sentence, and you should read it once in full before reading any chart:

"In the case of a hospital that has a hospital emergency department, if any individual (whether or not eligible for benefits under this subchapter) comes to the emergency department and a request is made on the individual's behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (within the meaning of subsection (e)(1)) exists."

Everything else follows from that sentence. If the screening finds an emergency medical condition, subsection (b) requires the hospital to stabilize it within the staff and facilities available, or to transfer the patient under subsection (c). Subsection (c) limits transfers of unstabilized patients. Subsection (h) bars delaying screening or stabilizing treatment to ask about payment or insurance. The regulation goes further and bars the hospital from seeking insurer authorization until after the screening is done and stabilizing treatment has started ([42 CFR 489.24(d)(4)(ii)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-489/subpart-B/section-489.24) ).

The table below is the one to print. For each duty it names the record that proves compliance or breach, and the defense you should expect the hospital to raise from its own chart.

| Duty | Source | Record that proves or defeats it | Common defense |
| --- | --- | --- | --- |
| Appropriate medical screening examination (MSE) | 1395dd(a); 489.24(a) | Triage note with time and ESI level; the provider note showing who examined, when, and what was ordered; results with times; the hospital's written screening policy or protocol for this complaint; the central log entry | "We gave her the same screening we give every patient with this complaint. The diagnosis was missed, which is a malpractice question, not an EMTALA one." |
| Stabilizing treatment | 1395dd(b); 489.24(d) | Orders and medication administration times; serial vital signs; reassessment notes; the admission order if the patient was admitted; the informed refusal form if treatment was declined | "No emergency medical condition was found," or "we admitted him in good faith as an inpatient, which ended our EMTALA duty," or "she refused treatment after being told the risks." |
| Appropriate transfer | 1395dd(c); 489.24(e) | Physician certification with its risk and benefit summary, or the patient's written request; receiving hospital acceptance (name, time, accepting physician); records sent; EMS run sheet; the receiving hospital's arrival vitals | "The patient was stable at transfer," or "the patient requested transfer in writing," or "the on-call specialist refused to come in, so transfer was the better choice." |
| No delay for payment | 1395dd(h); 489.24(d)(4) | Registration timestamps against triage and MSE times; financial counselor notes; insurance verification or authorization call logs | "Registration ran in parallel with care and did not delay the exam." |

Notice what the table leaves out: the standard of care. EMTALA does not ask whether the emergency physician was right. A hospital can follow its screening protocol to the letter, miss an aortic dissection, and have no EMTALA exposure at all; that is a negligence case. Most complaints plead both counts; the records overlap, the elements do not. For the negligence side, the [emergency department failure-to-diagnose review](https://medrecords.ai/solutions/emergency-department-failure-to-diagnose-review/) page covers what that record set looks like.

If you remember one thing
EMTALA measures the hospital against its own screening practice and the statute's transfer rules, not against the standard of care. Build every request and every timeline around that difference.

Chapter 2 Deciding

### When EMTALA applies: the definitions that decide the case

Many EMTALA claims die at the threshold, before anyone reads the physician note. The defense argues the patient never "came to the emergency department," that the condition was not an "emergency medical condition," or that the patient had become an inpatient. Each of those is a defined term, and the definitions live in the regulation, [42 CFR 489.24(b)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-489/subpart-B/section-489.24), more than in the statute.

Comes to the emergency departmentA person not already a patient who (1) presents at a dedicated emergency department and requests examination or treatment; (2) presents elsewhere on hospital property and requests treatment for what may be an emergency condition; (3) is in a hospital-owned and operated ambulance, even off grounds, with exceptions for community EMS protocols; or (4) is in a non-hospital ambulance on hospital property. A request is presumed when a prudent layperson observer would believe the person needs care. An ambulance that ignores a hospital's diversion and arrives on its property counts.
Dedicated emergency departmentAny department or facility of the hospital, on or off the main campus, that is licensed by the state as an emergency department, is held out to the public as offering unscheduled emergency care, or provided at least one-third of its outpatient visits in the prior calendar year for emergency conditions without an appointment. Labor and delivery and psychiatric intake units can qualify.
Hospital propertyThe entire main hospital campus, "including the parking lot, sidewalk, and driveway," but not separately certified entities such as physician offices, rural health clinics or skilled nursing facilities, or restaurants and shops.
Emergency medical conditionAcute symptoms of sufficient severity, "including severe pain, psychiatric disturbances and/or symptoms of substance abuse" in the regulation's wording, such that the absence of immediate medical attention could reasonably be expected to place health in serious jeopardy, seriously impair bodily functions, or cause serious dysfunction of any organ or part. For a pregnant woman having contractions, it also covers inadequate time for a safe transfer before delivery, or a transfer that may threaten the woman or the unborn child.
StabilizedNo material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer. For labor, delivery of the child and the placenta.
TransferMovement of the patient outside the hospital's facilities at the direction of hospital-affiliated staff, *including discharge*. It does not include a patient declared dead or one who leaves without the permission of hospital staff.
Inpatient admissionIf the hospital screens the patient, finds an emergency medical condition and admits the patient as an inpatient in good faith to stabilize it, its EMTALA duties to that patient end (489.24(d)(2)). The hospital Conditions of Participation govern the inpatient care that follows.
The inpatient exception depends on good faith, so an admission order written minutes before a transfer, or an admission that never produced inpatient care, invites the argument that it was paper cover.

The decision path below is the usual order of the questions. Each "yes" and "no" is a fact dispute litigated with records.

**Was EMTALA triggered, and was it met?** — decision path — 42 USC 1395dd; 42 CFR 489.24
1
**Is the hospital a Medicare participating hospital with a dedicated emergency department?**
YesGo to 2. For a department other than the main ED, check the license, signage and one-third test.
NoNo screening duty. A specialized hospital may still have to accept transfers (489.24(f)).
2
**Did the person come to the emergency department, as the regulation defines it?**
YesGo to 3. Pin down the time and place of presentation.
NoEMTALA was not triggered. Look at state law theories.
3
**Did the hospital give a medical screening examination, and was it the one it gives others with the same signs and symptoms?**
YesGo to 4. An even-handed screening that missed the diagnosis points to malpractice.
NoPossible screening violation: no MSE, a delayed one, or one that departed from the hospital's practice.
4
**Did the screening reveal an emergency medical condition?**
YesGo to 5. The stabilization and transfer duties now apply.
NoIf the screening was appropriate, EMTALA duties end here. Subsection (b) applies when "the hospital determines" an emergency condition exists, so what the chart says the hospital knew is the fight.
5
**Was the condition stabilized, or the patient admitted as an inpatient in good faith, before the patient left?**
YesDuties met, if the stability was real at the time the patient left.
NoGo to 6. The patient left unstable, by transfer or discharge.
6
**Was there a written patient request or a signed physician certification, and was the transfer appropriate under 1395dd(c)(2)?**
YesMet on paper. Test the paper: times, risk summary, acceptance, records sent, transport.
NoPossible transfer violation, unless an informed refusal is documented.
7
**Did the patient suffer personal harm as a direct result, and is the claim within 2 years of the violation?**
YesA civil action against the hospital is available under 1395dd(d)(2)(A).
NoNo private claim. A CMS complaint can still go forward.
Each box is a fact question the records answer. The path organizes the analysis; it does not decide whether EMTALA was violated.

A note on question 4. The stabilization duty in 1395dd(b)(1) is triggered when "the hospital determines that the individual has an emergency medical condition." Hospitals read that as a knowledge requirement: no finding in the chart, no duty to stabilize. Plaintiffs answer with the chart itself, pointing to abnormal vitals, results and nursing notes the hospital had in hand. How much knowledge a court requires, and how it is proven, is circuit case law; research yours before you plead it.

If you remember one thing
Discharge is a transfer under EMTALA. A patient sent home with an unstabilized emergency condition is analyzed under the transfer rules, and the chart has to show why the hospital believed the patient was stable.

Chapter 3 Deciding

### Disparate screening: the core medical screening theory

The statute never defines "appropriate medical screening examination." The courts filled the gap, and they filled it the same way in most circuits: appropriate means the screening the hospital would give any other patient with the same signs and symptoms, not the screening a careful physician should have given. The Fifth Circuit collected the cases in [*Marshall v. East Carroll Parish Hospital Service District*](https://www.ca5.uscourts.gov/Opinions/pub/97/97-30592.CV0.wpd.pdf) (1998). It agreed with the other circuits that EMTALA "was not intended to be used as a federal malpractice statute," and held that a screening is judged "by whether it was performed equitably in comparison to other patients with similar symptoms," not by whether it produced the right diagnosis. The First Circuit put it in 1 line, quoted there: "The essence of this requirement is that there be some screening procedure, and that it be administered even-handedly."

CMS reads it the same way. The interpretive guidelines surveyors work from say:

"The MSE must be the same MSE that the hospital would perform on any individual coming to the hospital's dedicated emergency department with those signs and symptoms, regardless of the individual's ability to pay for medical care."

Appendix V adds 2 points that plaintiffs use constantly. The MSE "is not an isolated event. It is an ongoing process that begins, but typically does not end, with triage." And "it is not appropriate to merely 'log in' an individual and not provide a MSE." Triage decides the order in which people are seen; the MSE decides whether an emergency medical condition exists. A triage note with vitals and a chief complaint, followed by a 4-hour wait and a departure, is a triage record and nothing more.

MythA missed diagnosis in the ED is an EMTALA violation.
RuleA misdiagnosis after an even-handed screening is a negligence question. The Fifth Circuit held that a failure to order an additional test "may constitute negligence or malpractice, but cannot support an EMTALA claim for inappropriate screening."
MythTriage counts as the screening exam.
RuleCMS treats triage as the start of the MSE, not the MSE. The record must show continued monitoring until the hospital determined whether an emergency condition existed.
MythThe plaintiff has to prove the hospital acted because the patient was uninsured.
RuleNot for stabilization: the Supreme Court held in *Roberts v. Galen of Virginia* (1999) that 1395dd(b) requires no improper motive. It expressly left the screening question open. The Sixth Circuit, under its 1990 *Cleland* decision, has required an improper motive for screening claims; *Roberts* noted that other circuits, including the First (*Correa*) and the Eighth (*Summers*), do not.
MythThe hospital has to prove it has a uniform screening policy.
RuleIn the Fifth Circuit the burden runs the other way: the plaintiff must show the patient was treated differently. The hospital's policy is still the best comparator you will get.

#### How disparity is proven from records

Disparate screening is a comparison, so you need 2 things: the standard, and the chart that departed from it. The standard is usually 1 of 4 documents, and I would ask for all 4 in the first request:

1. **The written triage and screening policy.** Appendix V tells surveyors to pull the ED policy manual on day 1. So should you.
2. **Complaint-specific protocols.** Chest pain, stroke, sepsis, labor. A protocol with a time target gives the timeline something to measure.
3. **EHR order sets as configured on the visit date.** The default orders for a complaint are the hospital's own statement of what screening looks like. Today's version is not evidence.
4. **Comparator charts.** What the hospital did for other patients with the same complaint. They need a protective order and de-identification, and they are where screening cases stall, but surveyors sample other records for "patterns of violations" for the same reason.

Then the chart. The departures that tend to matter are concrete: a protocol ECG never done, a pregnancy screen skipped, a psychiatric patient with no suicide risk assessment (Appendix V says the record should show "an assessment of suicide or homicide attempt or risk" for psychiatric presentations), a woman in labor with no fetal heart tones or cervical exam charted, or a screening that stopped when registration flagged the patient as uninsured. For obstetric screening claims, the [birth injury record review](https://medrecords.ai/solutions/birth-injury-record-review/) page covers the rest of that record set.

**Circuit check.** The screening standard is judge-made and the circuits differ at the edges: whether a delay in screening is itself a failure to screen, whether an improper motive is required, and who carries the burden on the hospital's policy. Read your circuit's cases before you frame the complaint.

If you remember one thing
A screening claim needs a yardstick. Ask for the triage policy, the complaint protocol and the order set as configured on the visit date in your first request, then measure the chart against them minute by minute.

Chapter 4 Everyone

### Stabilization, refusal and the transfer packet

Once the hospital determines that an emergency medical condition exists, it has 2 choices under 1395dd(b): stabilize within the staff and facilities available, or transfer under subsection (c). A third path is built into the statute. If the hospital offers the treatment or the transfer, explains the risks and benefits, and the patient refuses, the hospital is "deemed to meet" the duty, and it "shall take all reasonable steps to secure" a written informed refusal. The regulation adds that the medical record "must contain a description of the examination, treatment, or both if applicable, that was refused" ([42 CFR 489.24(d)(3)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-489/subpart-B/section-489.24) ).

That makes the AMA form 1 of the most important pages in the chart. A blank AMA form signed by the patient, with no description of what was refused and no risk discussion, is weak. A nurse note saying "pt refused to sign" can be enough; Appendix V tells surveyors that an unsigned form "is not, however, automatically a violation," provided staff documented the refusal and the hospital used best efforts to get a signature. Check who signed, at what time, and whether the time fits the rest of the timeline. An AMA form timed after the patient's departure in the central log is a finding.

#### The transfer rules, element by element

An unstabilized patient may be transferred only with 1 of 3 authorizations: the patient's informed written request; a physician certification that "based upon the information available at the time of transfer," the expected benefits of treatment elsewhere outweigh the increased risks; or a qualified medical person's certification, countersigned later by a physician. Every certification "shall include a summary of the risks and benefits upon which the certification is based." The transfer must also be "appropriate" under 1395dd(c)(2): treatment within the sender's capacity to minimize the risks, a receiving facility with space and qualified staff that has agreed to accept, all available records sent (including the name and address of any on-call physician who refused or failed to appear), and qualified personnel and equipment for the trip.

Here is what a transfer certification looks like when it is read the way an EMTALA reviewer reads it. The form is a mock-up; field names vary by hospital.

**Reading a transfer certification** — mock form, hypothetical — Elements from 42 USC 1395dd(c); 42 CFR 489.24(e)
Emergency transfer certification hypothetical
Condition
EMC present — Yes No1
Stabilized — Yes No2
Certification
Benefits — Neurosurgical care not available here3
Risks — Deterioration en route3
Physician signature — signed, dated, time blank4
Receiving facility
Accepted by — Dr. [name], 22:415
Records sent — Chart Imaging Labs6
Transport — ALS ground, 2 paramedics7
HOSP 000212
1. 1
**The hospital's own finding** A checked "yes" is the hospital determining an emergency condition exists. The stabilization duty in 1395dd(b) now applies.
2. 2
**Unstable transfer** "No" means subsection (c) governs. Compare with the last vitals before departure and the receiving hospital's arrival vitals.
3. 3
**Risk and benefit summary** Required by statute. Boilerplate that fits every patient is weak evidence that anyone weighed this patient's risks.
4. 4
**Signature time** The certification speaks to "the information available at the time of transfer." A blank time, or a time after departure, is a finding.
5. 5
**Acceptance** Name and time of the accepting physician. Match it to the receiving hospital's transfer center log and phone records.
6. 6
**Records sent** The statute requires records "available at the time of the transfer," including test results. Imaging and labs unchecked here is a gap to chase.
7. 7
**Qualified transport** Match the level of care to the EMS run sheet: crew certification, equipment, vitals en route.

Every field on the form maps to a statutory element. Read it field by field against the timeline, not as a signature page.

2 more rules sit on the receiving side. A hospital with specialized capabilities, such as a burn unit, shock-trauma unit or NICU, "may not refuse to accept" an appropriate transfer of a patient who needs those capabilities if it has the capacity (489.24(f)). And Appendix V tells a receiving hospital to report a suspected improper transfer to CMS or the state survey agency, with notification expected "within 72 hours of the occurrence." That report is often how a CMS investigation starts, and the receiving hospital's arrival record is often the best evidence of the patient's condition at the moment of transfer.

If you remember one thing
The certification, the acceptance, the records-sent list, the EMS run sheet and the receiving hospital's arrival note are 1 exhibit. Put them side by side with their times, and the transfer either holds together or it does not.

Chapter 5 Deciding

### The EMTALA lawsuit: who can sue, whom, and by when

The private right of action is in 1 subsection, and it is narrower than many first complaints assume.

"Any individual who suffers personal harm as a direct result of a participating hospital's violation of a requirement of this section may, in a civil action against the participating hospital, obtain those damages available for personal injury under the law of the State in which the hospital is located, and such equitable relief as is appropriate."

Read it for what it leaves out. The defendant is "the participating hospital." The statute gives no private civil action against the emergency physician, the on-call specialist or the physician group; claims against them run under state malpractice law. The damages are those "available for personal injury under the law of the State," so state damage caps and pre-suit rules become live arguments. Causation is built in: the harm must be "a direct result" of the violation. A plaintiff who was screened late but whose outcome was fixed before arrival has a causation problem, and the timeline is how both sides argue it.

Subsection (d)(2)(B) gives a second claim that is easy to forget: a medical facility that "suffers a financial loss as a direct result" of a hospital's violation can sue the hospital too. It gives a receiving hospital that absorbed the cost of an improper transfer its own claim against the sender.

#### The 2-year limit

Subsection (d)(2)(C) is blunt: "No action may be brought under this paragraph more than 2 years after the date of the violation with respect to which the action is brought." The clock runs from the violation, not from discovery of the harm and not from the end of treatment. It can be shorter or longer than the state malpractice period that governs the companion negligence claim, and the 2 periods may start on different days. Calendar both on intake. I would also calendar the EMTALA date from the earliest arguable violation, which is often the door time on the first visit, not the transfer hours later.

#### The government track runs in parallel

Separate from the civil action, the government enforces EMTALA 2 ways. CMS can terminate the hospital's Medicare provider agreement (489.24(g)). And the HHS Office of Inspector General can impose civil money penalties under 1395dd(d)(1) on the hospital and on a responsible physician, including an on-call physician, for negligent violations, such as certifying a transfer when the physician "knew or should have known that the benefits did not outweigh the risks." Gross and flagrant or repeated violations can bring physician exclusion.

$50,000 — statutory cap per violation, hospital of 100+ beds, 42 USC 1395dd(d)(1)(A)
$25,000 — statutory cap per violation, hospital under 100 beds, same subsection
$136,886 — 2025 inflation-adjusted maximum, 100+ beds or responsible physician, 45 CFR 102.3
$68,445 — 2025 inflation-adjusted maximum, under 100 beds, 45 CFR 102.3
HHS adjusts the statutory maximums for inflation every year in the penalty table at [45 CFR 102.3](https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-102/section-102.3), which points to the OIG's EMTALA penalty rule at 42 CFR 1003.510. Quote the current year's table, not the statute, when you cite a figure. Before CMS imposes a penalty, the statute requires it to ask the Quality Improvement Organization for a physician review of whether the patient had an unstabilized emergency condition, with at least 60 days for that review unless delay would jeopardize health or safety (1395dd(d)(3)).

Penalties are not damages and do not go to the patient. They matter to a civil case because the investigation behind them produces documents: the survey findings, the statement of deficiencies, and sometimes the QIO physician review. Chapter 6 covers how to get and use them.

##### EMTALA civil action

QuestionDid the hospital screen, stabilize and transfer as the statute requires, measured against its own practice?DefendantThe participating hospital onlyDeadline2 years from the violationDamagesState personal injury damages, plus equitable reliefKey recordsTimestamps, screening policy, central log, on-call list, transfer packet

##### ED malpractice claim

QuestionDid the care meet the professional standard of care?DefendantHospital, physicians, nurses, groupsDeadlineState statute of limitations, often with a discovery ruleDamagesState law, with any state capsKey recordsClinical notes, orders, results, expert review against the standard
If you remember one thing
The EMTALA damages claim runs against the hospital, within 2 years of the violation, for state-law personal injury damages. Physicians answer under state malpractice law and to the OIG, not under the private EMTALA action.

Chapter 6 Building

### CMS investigations and Form 2567 as evidence

An EMTALA complaint to CMS or the state survey agency can start an on-site investigation, and the surveyors' playbook is Appendix V of the [State Operations Manual](https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/som107ap_v_emerg.pdf). Read it before you draft discovery. It is the federal government's own list of the documents that show whether a hospital complied, and hospitals know surveyors ask for them, so they are hard to call burdensome.

#### What surveyors ask for on day 1

At the entrance conference, Appendix V tells surveyors to ask for the dedicated ED logs for the past 6 to 12 months, the ED policy and procedures manual (triage, labor assessment, transfers), consent forms for unstable transfers, ED committee and medical staff minutes, staffing schedules (physicians for 3 months, nurses for 4 weeks), the medical staff bylaws and roster, and physician on-call lists for the past 6 months.

#### How surveyors pick records, and why you should copy them

Appendix V says "a single occurrence is considered a violation," but surveyors still sample to find patterns: at least 20 records reviewed in depth (at least 10 on a revisit), chosen by the surveyor, never by hospital staff. The selection criteria double as a plaintiff's log review plan: transfers to other facilities; "gaps, return cases, or non-sequential entries in the log"; refusals of examination, treatment or transfer; patients who left against medical advice or without being seen; and patients who returned to the ED within 48 hours. Surveyors review the central log for at least 6 months and "check for completeness, gaps in entries or missing information." A physician, usually through the QIO, then decides whether the screening, stabilization and transfer were appropriate.

Each finding is written up under a tag number. Knowing the tags lets you read a statement of deficiencies quickly and match each citation to a duty.

| Tag | Rule | What the finding is about |
| --- | --- | --- |
| A/C-2400 | 489.20 | Policies and procedures addressing the anti-dumping provisions |
| A/C-2401 | 489.20(m) | Receiving hospital failed to report a suspected improper transfer |
| A/C-2402 | 489.20(q) | EMTALA rights signage |
| A/C-2403 | 489.20(r)(1) | Transfer records kept 5 years |
| A/C-2404 | 489.20(r)(2); 489.24(j) | On-call physician list and on-call policies |
| A/C-2405 | 489.20(r)(3) | Central log |
| A/C-2406 | 489.24(a), (c) | Appropriate medical screening examination |
| A/C-2407 | 489.24(d) | Stabilizing treatment |
| A/C-2408 | 489.24(d)(4), (5) | Delay in examination or treatment to inquire about payment |
| A/C-2409 | 489.24(e)(1), (2) | Appropriate transfer |
| A/C-2410 | 489.24(e)(3) | Whistleblower protections |
| A/C-2411 | 489.24(f) | Recipient hospital responsibilities |

#### Getting the Form CMS-2567

Findings go on Form CMS-2567, "Statement of Deficiencies and Plan of Correction." CMS began posting 2567s for short-term acute care hospitals and critical access hospitals from complaint surveys in March 2013, according to its survey memo [S&C 13-21](https://www.cms.gov/medicare/provider-enrollment-and-certification/surveycertificationgeninfo/policy-and-memos-to-states-and-regions-items/survey-and-cert-letter-13-21). The posted versions are redacted and carry no plan of correction; for the plan, and for the full survey file, send a Freedom of Information Act request to CMS or a public records request to the state survey agency, and follow with a subpoena if you need the surveyor's worksheets.

Admissibility at trial depends on your court's evidence rules. Even where a 2567 never reaches a jury, it does 3 jobs well. Appendix V tells surveyors to support every deficiency with evidence from record reviews and interviews, so the 2567 shows which other charts were pulled and that comparators exist. It quotes staff interviews, which become deposition outlines. And it often states what the hospital's own policy required, in the surveyor's words, which is the yardstick chapter 3 says you need.

**Do not overread a clean survey.** No deficiency on a 2567 means the surveyor did not substantiate a violation from the sample and evidence in front of them. It is not a finding that your client's screening was appropriate, and the civil claim does not depend on a CMS finding.

If you remember one thing
Appendix V is a discovery plan written by the government. Copy its entrance list and its sampling criteria into your requests, and the hospital will struggle to argue the documents are irrelevant.

Chapter 7 Building

### The ED record set to request

A standard "complete medical records" request gets the chart as the HIM department prints it, which is about half of an EMTALA file. The central log, the on-call list, the policies and the order-set configuration are hospital business records, not part of any 1 patient's chart, and they rarely arrive unless you name them. A patient's HIPAA access request (the covered entity has 30 days to act under [45 CFR 164.524](https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.524) ) is a fast way to get the chart itself; the rest comes through discovery or subpoena. The general mechanics are in [how to get medical records for a lawsuit](https://medrecords.ai/guides/how-to-get-medical-records-for-a-lawsuit/).

Retention helps you here. [42 CFR 489.20(r)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-489/subpart-B/section-489.20) requires both the sending and receiving hospital to keep "medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of the transfer," to keep an on-call list, and to keep a central log. Quote the rule in your preservation letter so nobody can claim routine deletion.

| Record | Who holds it | What it proves | Watch for |
| --- | --- | --- | --- |
| Registration and arrival record | Sending hospital (patient access) | Door time, mode of arrival, whether insurance questions came before triage | Registration time earlier than triage by a wide margin; insurance verification before the MSE |
| Triage note | Sending hospital (EHR) | Triage time, chief complaint, first vitals, ESI level, pain score | ESI level inconsistent with the vitals; "triage time" that is really the note's filing time |
| Nursing notes and vitals flowsheet | Sending hospital | Reassessments, trends, the last vitals before departure | Long gaps between reassessments; vitals charted in a batch after the fact |
| Physician or APP note | Sending hospital | Who did the MSE, when, what was examined, the EMC conclusion | Note signed hours after the encounter; exam time missing; templated negatives |
| Orders and results with times | Sending hospital (EHR, lab and imaging systems) | Ordered, collected, resulted and reviewed times for each test | Protocol tests never ordered; results that came back after discharge and were never seen |
| AMA, LWBS and refusal forms | Sending hospital | Informed refusal: what was refused, risks explained, who signed | Blank risk section; time after departure; no witness |
| Transfer certification and consent | Sending hospital | Authorization for an unstable transfer and the risk and benefit summary | Boilerplate reasons; missing time; signed by a non-physician with no countersignature |
| Receiving hospital acceptance | Both hospitals (transfer center) | Who accepted, when, and whether capacity was confirmed | Acceptance after departure; name missing; recorded calls not preserved |
| EMS run sheet (patient care report) | EMS agency | Condition at pickup, vitals en route, crew level, times | Vitals worse at pickup than the "stable" note; crew level below what the patient needed |
| Receiving hospital ED record | Receiving hospital | Condition and vitals on arrival: the best test of "stabilized" | Resuscitation on arrival; a receiving hospital report to CMS |
| Central log, 489.20(r)(3) | Sending hospital | That the patient came to the ED, and the disposition recorded | Disposition that contradicts the chart; gaps and non-sequential entries around the visit |
| On-call list, 489.20(r)(2), and paging logs | Sending hospital (medical staff office, operator) | Which specialist was on call, when paged, and whether they answered or refused | No specialist listed for a service the hospital offers; paging logs with short retention |
| Policies, protocols, order sets | Sending hospital | The screening yardstick for disparate screening | Today's version produced instead of the version in force on the visit date |
| EHR audit trail for the visit | Sending hospital (EHR vendor data) | When each note was opened, written, signed and amended | Late entries and addenda written after a complaint; see the EHR audit trail guide |

[](https://medrecords.ai/guides/ehr-audit-trail-medical-malpractice/)
A word on the ESI level. The Emergency Severity Index is a 5-level triage algorithm, from 1 (most urgent) to 5 (least urgent), that sorts patients by acuity and expected resource needs. The [AHRQ ESI page](https://www.ahrq.gov/patient-safety/settings/emergency-dept/esi.html) describes it; the Emergency Nurses Association has owned it since 2019. An ESI 2 who waited 3 hours is a different story from an ESI 4 who waited 3 hours, and an ED nurse expert can say whether the level fit the vitals.

##### 1. ED records request list for an EMTALA claim

Attach it to a subpoena, a request for production, or a preservation letter. Edit the bracketed fields and delete items that do not apply. Rules and procedure vary by jurisdiction.

RE: [PATIENT NAME], DOB [DATE]; ED visit(s) [DATE(S)]; [HOSPITAL NAME]
Time period: [DOOR DATE/TIME] through [DISPOSITION DATE/TIME + 24 HOURS]

A. Patient chart (produce in native EHR print format with all timestamps)
 1. Registration and arrival record, including arrival mode and insurance
 verification or authorization entries, with times
 2. Triage note(s), including chief complaint, vital signs, pain score and
 ESI or other acuity level, with the time each field was documented
 3. All nursing notes, reassessments and the vital signs flowsheet
 4. All physician, APP and resident notes, including the medical screening
 examination, with created, signed and amended times
 5. All orders, with ordered, collected, resulted and reviewed times
 6. Laboratory and imaging results, including imaging acquisition times
 7. Medication administration record
 8. Against-medical-advice, left-without-being-seen and informed refusal
 forms, and any note documenting a refusal to sign
 9. Transfer certification, patient transfer request or consent, and any
 qualified medical person certification with physician countersignature
10. Records of the receiving facility's acceptance: name of accepting
 physician, time, transfer center reference number
11. List or copy of the records sent with the patient
12. Discharge instructions and discharge time
13. Monitor, telemetry or fetal monitoring strips for the visit

B. Hospital records outside the chart
14. Central log entries under 42 CFR 489.20(r)(3) for [DATE], [DATE - 1]
 and [DATE + 1], de-identified for other patients as the court orders
15. On-call list under 42 CFR 489.20(r)(2) for [SPECIALTY/SPECIALTIES]
 for [DATE]
16. Paging, operator and phone logs showing calls to on-call physicians
 and to the receiving facility, and any recordings
17. ED triage, medical screening, transfer and on-call policies, and
 [COMPLAINT]-specific protocols and order sets, as in force on [DATE]
18. EHR audit trail for this encounter (access, create, modify, sign)
19. Any report to CMS or the state survey agency about this visit, any
 Form CMS-2567 and plan of correction arising from it
20. Diversion status logs for [DATE]

C. Third parties
21. EMS patient care report(s) from [AGENCY]
22. Receiving hospital ED and transfer center records from [HOSPITAL]

Preservation: records related to transfers must be kept 5 years under
42 CFR 489.20(r)(1). Please suspend routine deletion of the items above,
including phone recordings and paging logs.
If you remember one thing
The central log, the on-call list, the paging records and the policies in force on the visit date are not in the chart. Name each one in the first request, or you will be arguing about them after the depositions.

Chapter 8 Building

### Timestamp reconstruction: door, triage, MSE, disposition, transfer

EMTALA disputes are about intervals: how long from the door to triage, from triage to a provider, from a critical result to someone acting on it, from the transfer decision to acceptance to wheels rolling. The chart rarely hands you those intervals. You build them from every system that carries a clock, and you show your work.

Interval 1 — **Door to triage** — Registration or arrival time to the triage note. Sources: registration, EMS run sheet, triage note.
Interval 2 — **Triage to MSE** — Triage to the first provider evaluation. Sources: provider note exam time, first provider order, audit trail.
Interval 3 — **MSE to disposition** — Ongoing monitoring, tests and the EMC decision. Sources: orders, results, reassessments, disposition order.
Interval 4 — **Disposition to departure** — Transfer decision, certification, acceptance, transport. Sources: certification, transfer center log, EMS times, receiving ED arrival.

#### The method

1. **List every clock.** Registration, triage, note headers, orders, results, MAR, monitor strips, EMS run sheet, transfer center log, phone records, audit trail. Note which system owns each.
2. **Separate event time from documentation time.** A note "created 23:48" about an exam at 21:30 has 2 times. Record both, and cite the page for each. Many EMTALA timelines go wrong because a note's filing time was treated as the time of care.
3. **Find the offsets.** Use an event recorded in 2 systems (an arrival in both the EMS report and registration) to estimate each clock's offset. Note it; never silently correct it.
4. **Plot the anchor events.** Door, triage, first provider contact, EMC determination, stabilizing treatment, disposition decision, certification signed, acceptance, departure, arrival at the receiving hospital.
5. **Mark the gaps.** Any stretch with no reassessment, any interval beyond the hospital's own protocol, any expected record with no time.
6. **Put conflicts side by side.** When 2 records disagree, list both times and both sources. In EMTALA cases the disagreement is often the evidence.

##### 2. EMTALA timeline worksheet

1 row per event. Paste into a spreadsheet. Keep event time and documentation time in separate columns, and never fill a blank with an estimate without saying so.

CASE: [NAME] VISIT: [DATE] HOSPITAL: [NAME] PREPARED BY: [NAME]
Clock offsets noted: [SYSTEM A vs SYSTEM B: +/- MINUTES, BASIS]

# | Event | Event time | Documented time | Source (doc, page/Bates) | Author/role | Duty (MSE/Stab/Transfer/Delay) | Interval from prior anchor | Protocol limit (cite policy) | Conflict with other record? | Note
1 | Arrival / door | | | | | MSE | -- | | |
2 | Registration / insurance entry | | | | | Delay | | | |
3 | Triage, ESI level [ ] | | | | | MSE | | | |
4 | First provider contact (MSE start) | | | | | MSE | | | |
5 | Tests ordered [list] | | | | | MSE | | | |
6 | Results available / reviewed | | | | | MSE | | | |
7 | Reassessments [each one] | | | | | MSE/Stab | | | |
8 | EMC determination (yes/no, by whom) | | | | | Stab | | | |
9 | Stabilizing treatment [each] | | | | | Stab | | | |
10 | On-call paged / responded / refused | | | | | Stab/Transfer | | | |
11 | Disposition decision | | | | | Stab/Transfer | | | |
12 | Refusal / AMA form signed | | | | | Stab | | | |
13 | Transfer certification signed | | | | | Transfer | | | |
14 | Receiving facility accepted (name) | | | | | Transfer | | | |
15 | Records sent (list) | | | | | Transfer | | | |
16 | Departure / EMS pickup, vitals | | | | | Transfer | | | |
17 | Arrival at receiving ED, vitals | | | | | Transfer | | | |
18 | Central log disposition entry | | | | | All | | | |

GAPS (no record where one is expected): [LIST, with what implies the record]
CONFLICTS (2 sources, 2 times): [LIST, both citations]
If you remember one thing
Every time on your timeline needs 2 things: the page it came from, and whether it is the time of care or the time of charting. A timeline without both will not survive the first deposition.

Chapter 9 Building

### Worked example: a minute-by-minute ED timeline

**Hypothetical.** A 52-year-old self-pay man walks into a 90-bed community hospital's ED at 21:02 with chest pain radiating to his back. The hospital's written chest pain protocol (hypothetical) calls for an ECG within 10 minutes of arrival and nursing reassessment every 30 minutes for ESI 3 patients. He is transferred at 00:20 with a type A aortic dissection and arrives at a tertiary center at 00:55 hypotensive. No real patient, hospital or case is described. Bates numbers are invented.

**ED timeline with the gaps marked** — hypothetical — Illustration
1. 21:02
**Door**
Walk-in. Registration record shows arrival 21:02 and "self-pay" entered at 21:06, before triage.

Registration, HOSP 000002
2. 21:11
**Triage, ESI 3**
Chest pain to back, BP 182/104, HR 108, pain 9 of 10. No ECG ordered.

Triage note, HOSP 000004
3. 21:12
**Protocol ECG due, not done**
Policy calls for an ECG by 21:12. First ECG is at 22:31, 89 minutes late.

Chest pain protocol, HOSP 000301; ECG, HOSP 000019
4. 21:11 to 22:25
**74 minutes, no reassessment**
Flowsheet has no vitals between triage and the provider exam; protocol calls for 2 reassessments in that window.

Vitals flowsheet, HOSP 000011
5. 22:25
**Provider exam (MSE)**
Exam time stated in the note as 22:25; note created 23:48 and signed 01:12. 2 times, both cited.

ED physician note, HOSP 000006 to 000009
6. 22:50
**CT angiogram ordered**
Ordered 22:50, acquired 23:18, resulted 23:34: type A dissection.

Orders, HOSP 000014; CT report, HOSP 000022
7. 23:40
**EMC determination**
Physician addendum: "dissection, needs CT surgery, not available here." Labetalol ordered 23:41, given 23:52.

Addendum, HOSP 000009; MAR, HOSP 000024
8. 23:58
**Acceptance**
Receiving transfer center logs acceptance by a named cardiothoracic surgeon at 23:58.

Receiving transfer log, RCV 000003
9. 00:05?
**Certification time blank**
Transfer certification signed and dated, time field empty. Risk summary reads "benefits outweigh risks."

Transfer certification, HOSP 000027
10. 00:10
**Last vitals at sending ED**
BP 150/90, HR 96. Nurse note: "stable for transfer."

Vitals flowsheet, HOSP 000012
11. 00:14
**EMS contact vitals conflict**
Run sheet at patient contact: BP 88/50, diaphoretic, 4 minutes after the "stable" note. Departs 00:20.

EMS patient care report, EMS 000002
12. 00:55
**Arrival at receiving ED**
BP 80/46, taken straight to the OR.

Receiving ED note, RCV 000011
13. n/a
**Central log disposition**
Log records "discharged," not "stabilized and transferred" or "transferred."

Central log, HOSP 000350

5 marked gaps and 3 conflicting times, each with a citation. None of them decides the case; together they tell an expert and a lawyer where to look.

#### How each side reads the same timeline

##### What the plaintiff argues

Screening, transfer and delay theories

- The hospital skipped its own chest pain protocol for 89 minutes: a disparate screening claim measured against HOSP 000301.
- "Self-pay" was entered before triage; test whether it changed the order of care (1395dd(h)).
- The certification has no time and a boilerplate risk summary, so there is no proof a physician weighed the risks "at the time of transfer."
- EMS found him hypotensive 4 minutes after "stable for transfer"; he left unstabilized.
- The central log's "discharged" contradicts the chart.

##### What the hospital argues

Screening, stabilization and causation defenses

- Triage started the MSE at 21:11 and the ESI 3 level fit his presentation; any delay is a negligence question.
- No cardiothoracic surgery capability existed, so transfer was the only way to stabilize, and it was certified.
- The dissection, not the timing, caused the hypotension; the harm was not a "direct result" of any violation.
- The log entry is a clerical error; the chart shows a transfer.
- It will want the comparator charts too, expecting them to show the protocol is missed for every payer class.

My view: the missing certification time and the EMS vitals are the strongest facts, because they go to the transfer rules, where the statute is specific and no disparity comparison is needed. The protocol gap is a good screening theory only if the comparator charts show insured patients got their ECG on time. If they show the protocol is missed for everyone, the hospital has a bad ED rather than a disparity, and the claim looks more like malpractice than EMTALA. Whether any of this is an EMTALA violation is for the court and the experts.

If you remember one thing
Mark gaps as gaps and conflicts as conflicts, with both citations. The timeline's job is to show what the records say and where they disagree, not to decide the case.

Chapter 10 Everyone

### Using AI to rebuild an ED timeline: where it helps and where it fails

An EMTALA file is small by litigation standards, often a few hundred pages across 2 hospitals and an EMS agency, but dense with times. Generative AI built on a large language model (LLM) handles the tedious part of AI medical record review: pulling every timestamp from triage notes, flowsheets, order logs and run sheets, putting them in order, and noticing a note created 83 minutes after the exam it describes. Older clinical NLP (natural language processing) tools extracted terms; an AI medical chronology drafts the timeline itself. A newer wrinkle: ambient AI scribes now draft some ED notes from recorded conversation, so a note's text, draft time and signature time can be 3 different things. And the software can be wrong in ways that cost more here than in most claims.

Where AI helps
Extraction — Every time in every document, including the ones a tired reader skips
Ordering — Events from 3 providers merged into 1 timeline
Conflicts — 2 records giving 2 times for 1 event, surfaced side by side
Gaps — Expected records missing, such as a transfer with no certification
Where it fails
Hallucination — A plausible time or finding that no page contains
OCR — Faxed run sheets where 21:11 reads as 21:17, or 0014 as 0044
Handwriting — Handwritten entries on paper transfer forms and EMS sheets
Documentation time — Treating a note's filing time as the time of care
The fixes are known. Every line should carry a grounded, page-level citation, so a reviewer clicks from "EMS BP 88/50 at 00:14" to the run sheet page. Retrieval-augmented generation (RAG) that answers only from the uploaded pages reduces invented facts but does not remove them. OCR should flag low-confidence pages, especially faxes and handwritten notes, so a human reads them directly. And human-in-the-loop review is required: the ED nurse expert or LNC checks every time that matters against its page. Courts have sanctioned lawyers under Rule 11 for filing AI-invented case citations, *Mata v. Avianca* (S.D.N.Y. 2023) being the best known, and a timeline with an invented minute is the same risk in a different document.

#### Checklist for legal AI tools on an EMTALA file

- **HIPAA compliant AI with a signed BAA** *You are uploading PHI; no business associate agreement, no upload.*
- **SOC 2 report available** *Ask for it; read the exceptions.*
- **No training on your data** *Put it in the contract; a web page is not enough.*
- **A citation on every line** *Every time and finding links to its source page.*
- **Event time and documentation time kept apart** *Test it on a note signed hours after the exam.*
- **Low-confidence OCR flagged** *Faxed EMS and transfer forms are where times get misread.*
- **Gaps and conflicts shown, not resolved** *The tool should show both times, not pick one.*
- **A log of AI use on the file** *Who ran what, when, and what was edited.*

**0** of 8 checked

If you remember one thing
Use AI to find every time in the file and every place 2 records disagree. Then have a person check each time that matters against its page before anyone relies on it.

Chapter 11 Publisher

### Where Medrecords AI fits

Medrecords AI is medical record review software. You upload the records you have; it drafts a [cited medical chronology](https://medrecords.ai/product/chronology/) of arrival, triage, provider contact, orders, results, treatment and transfer, with [a citation on every line](https://medrecords.ai/product/citations/) linked to its source page. [OCR](https://medrecords.ai/product/ocr/) routes typed, handwritten and table pages to the right engine and flags low-confidence pages. [Missing records identification](https://medrecords.ai/product/missing-records-identification/) flags documents the file implies but does not contain, such as a transfer mentioned in a note with no certification produced. [Undated document flagging](https://medrecords.ai/product/undated-document-flagging/) catches the forms with no time. When the receiving hospital's records arrive later, [supplemental record review](https://medrecords.ai/product/supplemental-record-review/) shows where they agree with, conflict with or add to the file.

What it does not do: it does not retrieve records from hospitals or EMS agencies, does not decide whether EMTALA applied or was violated, and does not give legal or medical opinions. Flags are signals, not verdicts. You review, you revise, you sign.

The offer

#### See your ED timeline built with a citation on every minute.

Book a demo on an EMTALA file you are working, then run your first case free on us. Every line comes back cited to its source page. You review, you revise, you sign.

[Book a demo](https://medrecords.ai/demo/) [See the cited chronology](https://medrecords.ai/product/chronology/)
Scheduling only. No records move from a public page.

Chapter 12 Everyone

### Frequently asked questions

What counts as an EMTALA violation?A participating hospital's failure to give an appropriate medical screening examination to someone who comes to its emergency department, to stabilize an emergency medical condition it finds, or to follow the transfer rules for an unstable patient. Delaying screening or treatment to ask about payment is also prohibited.
Can you sue a doctor for an EMTALA violation?Not under the private action. 42 USC 1395dd(d)(2)(A) runs against the participating hospital. Physicians can face OIG civil money penalties and exclusion under 1395dd(d)(1)(B), and state malpractice claims.
What is the statute of limitations for an EMTALA claim?2 years from the date of the violation, under 1395dd(d)(2)(C). The state malpractice period for a companion claim may be different, so calendar both.
Is triage the medical screening examination?No. CMS says the MSE "begins, but typically does not end, with triage." Triage sets the order patients are seen; the MSE decides whether an emergency condition exists.
Can AI build an EMTALA timeline from ED records?It can extract and order the timestamps and flag conflicts and missing records, provided every line cites its source page. It cannot decide what the times mean, and a person should verify each important time against the page, especially on faxed or handwritten forms.
Is it HIPAA compliant to upload ED records to AI software?It can be, if the vendor signs a business associate agreement, secures the data and does not train on it. A consumer chatbot without a BAA is not the place for a patient's chart.
Can ChatGPT summarize medical records for an EMTALA lawsuit?A general chatbot can summarize text, but without page-level citations you cannot check its times, and it may invent them. For litigation, use HIPAA compliant AI built for record review, and verify before you rely on it.
Does Medrecords AI decide whether EMTALA was violated?No. It builds a cited chronology and flags gaps and conflicts in the records you upload. Lawyers, experts and courts decide the rest.

Chapter 13 Everyone

### Sources and method

Statutes, regulations and CMS guidance were checked against primary sources in September 2026, and quoted text is verbatim. Circuit case law was read through the Fifth Circuit's opinion in *Marshall*, which quotes the other circuits; those quotations are cited as *Marshall* reports them. The hospital, patient and times in chapter 9 are hypothetical. Product facts come from this site's product pages. Nothing here is legal or medical advice.

- [42 USC 1395dd](https://www.law.cornell.edu/uscode/text/42/1395dd): duties in (a), (b), (c); penalties and civil action in (d); definitions in (e); no delay in (h).
- [42 CFR 489.24](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-489/subpart-B/section-489.24): definitions, inpatient exception, refusal, prior authorization, transfer, recipient hospital, on-call.
- [42 CFR 489.20(q) and (r)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-489/subpart-B/section-489.20): signage, 5-year transfer records, on-call list, central log.
- [45 CFR 102.3](https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-102/section-102.3): 2025 adjusted maximums for 1395dd(d)(1) penalties.
- [CMS State Operations Manual, Appendix V](https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/som107ap_v_emerg.pdf) (Rev. 191, 2019): entrance list, sampling, record review, tags A/C-2400 to 2411, MSE and central log guidance, 72-hour report.
- [CMS S&C 13-21-ALL](https://www.cms.gov/medicare/provider-enrollment-and-certification/surveycertificationgeninfo/policy-and-memos-to-states-and-regions-items/survey-and-cert-letter-13-21) (2013): posting of hospital Form CMS-2567s.
- [*Roberts v. Galen of Virginia, Inc.*](https://www.law.cornell.edu/supremecourt/text/97-53), 525 U.S. 249 (1999).
- [*Marshall v. East Carroll Parish Hospital Service District*](https://www.ca5.uscourts.gov/Opinions/pub/97/97-30592.CV0.wpd.pdf), No. 97-30592 (5th Cir. 1998).
- [AHRQ, Emergency Severity Index](https://www.ahrq.gov/patient-safety/settings/emergency-dept/esi.html).
- [45 CFR 164.524](https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.524): HIPAA right of access, 30 days.
- *Mata v. Avianca, Inc.*, 678 F. Supp. 3d 443 (S.D.N.Y. 2023): Rule 11 sanctions for fabricated AI-generated citations.

Related guides: [EHR audit trails in medical malpractice](https://medrecords.ai/guides/ehr-audit-trail-medical-malpractice/), [altered medical records](https://medrecords.ai/guides/altered-medical-records/), [how to write a medical chronology](https://medrecords.ai/guides/how-to-write-a-medical-chronology/), and [medical malpractice record review](https://medrecords.ai/solutions/medical-malpractice/).

### More guides

- [**HIPAA and AI medical record review: what to verify** — A buyer checklist for HIPAA compliant AI medical record review: the agreements, encryption, data residency, and…](https://medrecords.ai/guides/hipaa-compliant-ai-medical-record-review/)
- [**History and physical: what each part means and how to test it against the chart** — What goes in a history and physical, CMS 30-day and 24-hour rules, what studies show about copied and templated…](https://medrecords.ai/guides/history-and-physical/)
- [**How much does medical record review cost?** — What medical record review and chronology work costs in 2026: per-page, per-hour, and per-case rates compared…](https://medrecords.ai/guides/medical-record-review-cost/)
- [**How to become an AI-native IME physician in 2026** — What IME and QME work pays, how to get certified, and where AI belongs in the record packet. Built on RAND…](https://medrecords.ai/guides/ai-native-ime-physician/)
- [**How to become an AI-native legal nurse consultant in 2026** — How to become a legal nurse consultant in 2026: salary, certification, the first case, and running the practice…](https://medrecords.ai/guides/ai-native-legal-nurse-consultant/)
- [**How to become an AI-native personal injury law firm in 2026** — How to re-architect a contingency PI firm around AI: demand generation, practice-area pods, case data, and the…](https://medrecords.ai/guides/ai-native-personal-injury-law-firm/)